MONDAY, Sept. 24, 2018 (HealthDay News) -- American teens whose behavior, appearance or lifestyle do not conform to widely held views on what it is to be a "normal" male or female face a high risk for mental distress and drug abuse, new research warns.

The findings were culled from a national survey exploring the psychological risk profiles of teens who described themselves as "gender nonconforming."

The poll enlisted more than 6,000 students enrolled in high schools in three large urban school districts across California and Florida.

"Gender nonconformity is gender expression that differs from societal expectations for feminine or masculine appearance and behavior," explained study author Michelle Johns. As such, it's an "area of adolescent health that is often linked to negative health outcomes."

In fact, previous research has suggested that gender nonconforming individuals often struggle with "social stress," due to stigma, discrimination, harassment and violence, noted Johns, a health scientist in the division of adolescent and school health at the U.S. Centers of Disease Control and Prevention.

But this latest study, she said, "is among the first to examine mental distress and substance use among gender nonconforming youth."

In the end, the team found that nonconforming girls and boys in high school faced a higher risk for feeling sad, feeling hopeless, and entertaining suicidal thoughts and/or suicidal behavior. Substance abuse risk also rose, investigators observed.

About 55 percent of those surveyed were Hispanic, while about 16 percent were white and 19 percent were black.

Students were asked to indicate how their peers would characterize their gender, based on their "appearance, style, dress, or the way they walk or talk."

On that basis, about 1 in 5 said they were either "moderately" or "highly" gender nonconforming. Boys were more likely to say they were gender nonconforming than girls, as were younger students and those who were LGBTQ.

Among moderately nonconforming girls, half said they felt sad and hopeless, a figure that dipped to 45 percent among their highly nonconforming peers. That, said investigators, could reflect the particular difficulties of navigating a middle pathway when tackling gender identity.

Sadness and hopelessness was seen among about a third of moderate and highly nonconforming boys.

About a third of moderate and highly nonconforming girls said they seriously contemplated suicide; those figures dipped to 14 and 22 percent among boys.

That said, Johns acknowledged that her team "cannot determine whether these numbers are reflective of high school students across the United States," given that the survey included a larger-than-average sample of minorities and city dwellers.

"However, these findings suggest that developing support systems within schools and other school-based interventions, such as safe spaces and supportive/knowledgeable staff for gender nonconforming students, may be an important avenue to improving mental health and reducing substance use in this population," she said.

Dr. Ellen Selkie, clinical lecturer of adolescent medicine in the department of pediatrics at the University of Michigan, had some additional suggestions, including the "Human Rights Campaign" (www.hrc.org/explore/topic/transgender-children-youth) and "The Trevor Project" (www.thetrevorproject.org).

And in an accompanying editorial, Selkie observed that the study adds some insight into an under-researched concern.

Much of the observed distress, said Selkie, seems likely to stem from a "lack of acceptance from family community," with nonconforming youth facing a struggle for acceptance that can be as complex and nuanced as gender nonconformity itself.

For example, she noted that one's gender identity is distinct from one's sexuality, but "I have had gender nonconforming patients from conservative rural areas who have been very supported at school and home, and I have also had patients from liberal, urban areas who feel very unsupported and experience bullying at school."

Much more research will be needed, Selkie said, to better appreciate the hurdles faced by nonconforming youth.